Earlier this week we posted a discussion about the subtle changes in EC.02.06.05, adding just two words to the statement yet having a profound impact. (Read that blog post here.) Today we would like to discuss the other new standard related to managing maintenance related risks. EC.02.05.05 EP1 now states,
“When performing repairs or maintenance activities, the hospital has a process to manage risks associated with air-quality requirements; infection control; utility requirements; noise, odor, dust, vibration; and other hazards that affect care, treatment, or services for patients, staff, and visitors.”
In short, this new requirement is an extension of what we’ve been doing with construction risks since 2001. At first glance, the amount of work involved seems overwhelming. How do you create a process where each work order is assessed for its impact on all of the above stated factors? As we stated in the previous post, expecting maintenance personnel to go through our current infection control risk assessment (ICRA) process is a bit ambitious. How then can we reduce their work load to a more manageable level?
First, we must understand that identifying the risks is only the beginning. Proper mitigation is the key to protecting everyone involved. In a perfect world, the risks would be the same regardless of where we are working or who we are working around; however, we know that risks are far from static and can change over a very short period. That being said, we can do much of the work on a macro level and make minor adjustments as required.
Allow us to explain a bit further. It is possible for an organization to do a generalized risk assessment based on the types of patients and services offered in the various areas of the facility. For example, we know that our operating rooms will always be high risk, whereas administration will usually be low. By identifying the normal risk of a specific area, we may also develop standard mitigation plans for whatever work is being performed there. These can be added as notes or tasks within our maintenance management systems. This ground work can serve as the foundation for educating your team on the risks and tools used to reduce them.
Staff education will be the most effective way to identify and manage the variable risks that may occur at any time. Their foundation of knowledge regarding these risks and mitigation methods, coupled with effective communications with their clinical counterparts, will allow them to adjust the standard procedures as necessary to protect those patients that may be higher than normal risks. These modifications may be documented via the work order or maintenance management system.
In many of the discussions we’ve had about this standard since its proposal, the first reaction seems to be, “it’s impossible!” However, we believe that it is not only possible, but imperative towards achieving the goal of zero preventable deaths.